· Concurrent Review: Conduct concurrent reviews of inpatient medical records to assess the necessity and appropriateness of services provided, ensuring alignment with insurance company guidelines.
· Insurance Communication: Act as a liaison between the hospital and insurance companies, providing clinical information and justifications for services rendered.
· Claim Management: Determine claimable and non-claimable items and procedures based on insurance policies and medical necessity. Determine the appropriate ICD codes.
· Documentation Review: Ensure accurate and complete documentation of patient care, including medical records, treatment plans, and discharge summaries, to support insurance claims.
· Pre-authorization and Certification: Obtain pre-authorizations and certifications for procedures and services as required by insurance companies.
· Appeals and Denials: Prepare and submit appeals for denied claims, providing supporting documentation and clinical rationale.
· Compliance: Maintain up-to-date knowledge of insurance policies, regulations, and coding guidelines.
· Collaboration: Collaborate with physicians, nurses, and other healthcare professionals to ensure efficient and effective utilization of resources and timely claim submission.
· Data Analysis: Analyze utilization data to identify trends and areas for improvement in resource management and claim accuracy.
· Document Preparation: Ensure all documents are appropriately filled and prepared for insurance submission, including but not limited to, medical reports, lab results, and imaging studies.
· Training: Provide training and education to hospital staff on insurance requirements and documentation standards.